Charles L Wallace, LADAC

Primary specialty

Addiction (Substance Use Disorder) CounselorTaxonomy code 101YA0400X

License

3628 Issued in NM

Practice address

653 W Arrington St
Farmington, NM 87401-8513

Phone

(505) 564-3733

NPI assigned

Nov 15, 2012

Last updated

May 22, 2025By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Cottonwood Clinical Services, Inc.

  • Community/Behavioral Health Agency
  • Farmington, NM
  • NPI 1790019420

  Addiction (Substance Use Disorder)

  NPD
• Cottonwood Clinical Services, Inc.

  • Community/Behavioral Health Agency
  • Farmington, NM
  • NPI 1790695849
  NPD (past)
• Jasper and Associates, LLC

  • Counselor
  • Farmington, NM
  • NPI 1891073466

  Addiction (Substance Use Disorder)

  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1352937600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1747872000000",
    "number": "1902140932",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "653 W ARRINGTON ST",
            "city": "FARMINGTON",
            "state": "NM",
            "postal_code": "874018513",
            "telephone_number": "505-564-3733"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "653 W ARRINGTON ST",
            "city": "FARMINGTON",
            "state": "NM",
            "postal_code": "874018513",
            "telephone_number": "505-564-3733"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "CHARLES",
        "middle_name": "L",
        "credential": "LADAC",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2012-11-15",
        "last_updated": "2025-05-22",
        "certification_date": "2025-05-22",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YA0400X",
            "taxonomy_group": "",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": "NM",
            "license": "3628",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Walgreen Co (Walgreens #04510)
• Walgreen Co. (Walgreens #09067)
• Barbara Walker
• Chainey Walker
• Donna Doreen Walker, RPH
• John Walsh IV, CSW
• Carl Lee Wamboldt
• Briana Mae Ward
• Lawrence O Ward, DPM
• Kara L. Washburn, B.S.W., LSAA

• Addiction (Substance Use Disorder) Counselor in Farmington, NM
• Providers in Farmington, NM by specialty
• Addiction (Substance Use Disorder) Counselor in New Mexico

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 22, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.